APPLICATION FOR ADOPTION OF A CHILD I. IDENTIFYING INFORMATION

1 Annual Income: $_____ Earnings Retirement Public Assistance SSI/ social Security Support Payments Other Income:$ _____STATE OF california - HEALTH AND HUMAN services AGENCYCALIFORNIA department OF social SERVICESAPPLICATION FOR ADOPTION OF A CHILDI. IDENTIFYING INFORMATIONAD 521 (8/11) PAGE 1 of 4 Home AddressCityCountyZip CodeHome Telephone Number( )Mailing AddressCityCountyZip CodeAPPLICANT(S) ADDRESSLast Name First NameMiddle NameMaiden NameAKA sDate of BirthPlace of BirthGenderRace/EthnicityDriver License NumberOccupationWork Telephone Number( )Cell Telephone Number( )

2 Email AddressLevel of Education 8th Grade High School Graduate GED Graduate Trade/Vocational Graduate 2 Year College Graduate 4 Year College Graduate Post GraduateSocial Security NumberEmployer s Name and AddressMarital Status: Married Domestic Partnership Legally Separated Single Widowed DivorcedAPPLICANT 1 Annual Income: $_____ Earnings Retirement Public Assistance SSI/ social Security Support Payments Other Income:$ _____Last Name First NameMiddle NameMaiden NameAKA sDate of BirthPlace of BirthGenderRace/EthnicityDriver License NumberOccupationWork Telephone Number( )Cell Telephone Number( )Email AddressLevel of Education 8th Grade High School Graduate GED Graduate Trade/Vocational Graduate 2 Year College Graduate 4 Year College Graduate Post GraduateSocial Security NumberEmployer s Name and AddressMarital Status.

3 Married Domestic Partnership Legally Separated Single Widowed DivorcedAPPLICANT 2 Full NameDateof BirthGenderLives inHomeYes/NoDo you FinanciallySupport ChildYes/NoRelated to:AdoptedYes/NoAD 521 (8/11) PAGE 2 of 4II. MARITAL HISTORYF ormer MarriagesNames of Former SpousesApplicant 1 Applicant 2 Marriage Date & PlaceDivorce Date & PlaceDeath Date & PlaceIII. CRIMINAL HISTORYA pplicant 1 Applicant 2A. Have you ever been arrested for an offense other than a minor traffic violation? Yes No Yes NoB. Have you ever been convicted of a crime in california ? Yes No Yes NoYou need not disclose any marijuana-related offenses covered by the marijuana reform legislation codified at Health and Safety Code sections and Have you ever been convicted of a crime in another state, federal court, Yes No Yes Nomilitary or a jurisdiction outside of the convictions from another state or federal court are considered the same as criminal convictions in Have you ever been reported to Children s Protective services or Law Yes No Yes NoEnforcement for alleged CHILD abuse, neglect or abandonment?

4 E. Other states resided in within last five CHILDREN OF APPLICANT(S)IV. CHILDREN OF APPLICANT(S)Date of Current Marriage/Domestic PartnershipPlace of Marriage/Domestic Partnership (City and State) Marriage Domestic Partnership Applicant 1 Applicant 2 Applicant 1 Applicant 2 Applicant 1 Applicant 2 Applicant 1 Applicant 2 Applicant 1 Applicant 2 Full NameDateof BirthGenderLives inHomeYes/NoDo you FinanciallySupport AdultChildYes/NoRelated to:Address/Phone NumberAdoptedYes/NoADULT CHILDREN OF APPLICANT(S) Applicant 1 Applicant 2 Applicant 1 Applicant 2 Applicant 1 Applicant 2 Applicant 1 Applicant 2 Applicant 1 Applicant 2VI.

5 FOSTER CARE/ ADOPTION HISTORY1. Are you licensed for foster care? Ye s NoIf yes, check one: County State/CCL2. Are you certified for foster care with a Foster Family Agency (FFA)? Ye s NoIf yes, name of Agency(s):_____3. Were you previously licensed or certified for foster care? Ye s NoIf yes, name of Agency(s):_____4. Have you previously applied for ADOPTION ? Ye s NoIf yes, name of Agency(s): _____AD 521 (8/11) PAGE 3 of 4V. OTHER PERSONS IN THE HOMEADULT(S) AND/OR MINOR(S)Full NameDate of BirthRelationship to Applicant(s)VII. CHILD DESIREDIF A CHILD HAS BEEN IDENTIFIED:Is CHILD currently in the home?

6 Ye s NoFull NameDate ofBirthEducation (Name & Address ofSchool & Grade)Relationship to Applicant(s)Date of Placement or FutureDate to be PlacedCounty ofDependencyIF CHILD HAS NOT BEEN IDENTIFIED, PLEASE INDICATE YOUR PREFERENCES: 0 to 3 yrs. 4 to 8 yrs. 9 to 12 yrs. 13 to 15 yrs. 16 to 18 yrs. Caucasian Hispanic African/Amer Asian Native American Other History of Physical Abuse/Neglect History of Sexual Abuse History of Mental Illness Medically Fragile Physically Disabled Intellectually Challenged Learning Disabled Alcohol/Drug Exposed Oppositional/Defiant Behavior Adverse Parental Background Different Religious Faith Different Ethnic and/orCultural Background 2 3 4 5 or more Male Only Female Only No PreferenceAge(s)GenderEthnicitySibling(G roup of)Check All Conditions that You are Willing to Accept AD 521 (8/11)

7 PAGE 4 of 4 VIII. REFERENCESNameProvide Directions To Your Home:Telephone NumberMailing Address/City/State/ZipPlease list the name, address and telephone numbers of four individuals who have knowledge of your home environment,lifestyle and capability to be an adoptive parent. At least two of these must be unrelated to affirm that the INFORMATION provided on this form is true and correct to the best of my/our signing this APPLICATION , I/we understand that the completion of routine forms will be required of my/our references, physician,and employer and that my/our financial and marital status will be verified and a criminal background check will be OF APPLICANT 1 SIGNATURE OF APPLICANT 2